Page 8 - SIH 2022 Re-Enrollment Guide
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DENTAL AND VISION PRICING
Total Monthly Rate Employee Monthly Contribution Employee Cost Per Pay Period
Dental—High Option
Employee Only $38.40 $38.40 $19.20
Employee + Spouse $80.65 $80.65 $40.33
Employee + Child(ren) $69.13 $69.13 $34.57
Employee + Family $122.90 $122.90 $61.45
Dental—Low Option
Employee Only $25.12 $25.12 $12.56
Employee + Spouse $52.76 $52.76 $26.38
Employee + Child(ren) $45.22 $45.22 $22.61
Employee + Family $80.38 $80.38 $40.19
Vision
Employee Only $5.68 $5.68 $2.84
Employee + Spouse $10.72 $10.72 $5.36
Employee + Child(ren) $11.27 $11.27 $5.64
Employee + Family $16.53 $16.53 $8.27
DENTAL PLAN DESIGN
SIH Dental Coverage High Option (A) Low Option (B)
Annual Deductible (per covered person for basic services) $50 $100
100% coverage/ 100% coverage/
Preventive Service (cleanings, luoride, routine exams, x-rays)
no deductible no deductible
80% coverage 60% coverage
Basic Services (illings, extractions, root canal, etc.)
after deductible after deductible
50% coverage 50% coverage
Major Services (bridges, dentures, inlays, crowns, etc.)
after deductible after deductible
Annual Maximum Beneit (excluding orthodontic treatment) $1,500 $1,250
Orthodontics (lifetime maximum beneit) $1,500 $1,250
The dental plan documents are available online by visiting Employee Self Service and Beneits Plans &
Coverage under the Home tab on the Lawson Dashboards and at beneits.sih.net. If you do not have
access to a computer, printed copies are available upon request from Human Resources.
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Total Monthly Rate Employee Monthly Contribution Employee Cost Per Pay Period
Dental—High Option
Employee Only $38.40 $38.40 $19.20
Employee + Spouse $80.65 $80.65 $40.33
Employee + Child(ren) $69.13 $69.13 $34.57
Employee + Family $122.90 $122.90 $61.45
Dental—Low Option
Employee Only $25.12 $25.12 $12.56
Employee + Spouse $52.76 $52.76 $26.38
Employee + Child(ren) $45.22 $45.22 $22.61
Employee + Family $80.38 $80.38 $40.19
Vision
Employee Only $5.68 $5.68 $2.84
Employee + Spouse $10.72 $10.72 $5.36
Employee + Child(ren) $11.27 $11.27 $5.64
Employee + Family $16.53 $16.53 $8.27
DENTAL PLAN DESIGN
SIH Dental Coverage High Option (A) Low Option (B)
Annual Deductible (per covered person for basic services) $50 $100
100% coverage/ 100% coverage/
Preventive Service (cleanings, luoride, routine exams, x-rays)
no deductible no deductible
80% coverage 60% coverage
Basic Services (illings, extractions, root canal, etc.)
after deductible after deductible
50% coverage 50% coverage
Major Services (bridges, dentures, inlays, crowns, etc.)
after deductible after deductible
Annual Maximum Beneit (excluding orthodontic treatment) $1,500 $1,250
Orthodontics (lifetime maximum beneit) $1,500 $1,250
The dental plan documents are available online by visiting Employee Self Service and Beneits Plans &
Coverage under the Home tab on the Lawson Dashboards and at beneits.sih.net. If you do not have
access to a computer, printed copies are available upon request from Human Resources.
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